Provider Demographics
NPI:1982007977
Name:BOONE, TINA
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:BOONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 679
Mailing Address - Street 2:
Mailing Address - City:MORRILTON
Mailing Address - State:AR
Mailing Address - Zip Code:72110-0679
Mailing Address - Country:US
Mailing Address - Phone:501-354-4589
Mailing Address - Fax:501-354-5410
Practice Address - Street 1:816 N. CREEK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032
Practice Address - Country:US
Practice Address - Phone:501-329-5848
Practice Address - Fax:501-329-5848
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator